The Liberating Potential of Pragmatism

A couple of years ago Malcolm Gladwell published a provocative and thought provoking article in the New Yorker suggesting that our common-currency instincts about social desert might run contrary to and impede good policy. Relying in part on the apocryphal tale of “Million Dollar Murray,” Gladwell made the case that the solutions to many of our most expensive social challenges may not require systemic change or large policy initiatives. Rather, we might see the greatest effect by focusing our attentions on a few key players. “Murray” was one candidate. An often homeless man with a tendency to binge, Murray and a relatively small cohort of mostly non-violent homeless addicts, according to Gladwell, cost taxpayers and public institutions in Reno Nevada hundreds of thousands of dollars in a matter of months split between police officers, emergency services, and public hospitals. Gladwell quotes one official estimating that during his decade living on the streets of Reno, local hospitals spent more than a million dollars on Murray alone. The solution to massive law enforcement, emergency services, and public health cost overruns, Gladwell went on to suggest, might be to identify the most expensive consumers of these resources and give them free housing, a personal social worker, job training, and free healthcare. The sticking point, of course, is that doing so would seem to reward bad behavior, inverting our common notions of desert and opening the door to a moral hazard problem.

In somewhat less provocative style, Atule Gwande recently made a similar case for aggressive primary care, also in the New Yorker. The focus of Gwande’s reporting is a project in Camden, New Jersey, called the Camden Coalition of Healthcare Providers, which was founded by Jeffrey Brenner. According to Gwande, as a young family medicine practitioner in Camden, Brenner noticed that many ambulance runs and hospital visits originated in a handful of neighborhoods in Camden. As he dug into the data more, he calculated that one percent of Camden’s population was responsible for over thirty percent of its emergency medicine and crisis inpatient costs. Once he had the data really dialed in, Brenner discovered that the residents of a couple of buildings consumed millions of dollars a year in healthcare costs that Brenner considered avoidable because they were the consequence of bad primary care, poor follow-up, and an incapacity to capture and make available to multiple providers crucial patient information. The Camden Coalition is designed as an experimental alternative. By providing to these neediest of consumers easy local access to physicians, aggressive follow-up from by medical professionals, and life-coaching to help them break bad habits and develop good health practices, the Coalition has already achieved a significant decrease in overall healthcare costs for the group and therefore Camden, though, here again, moral hazard looms.

What intrigues me about these sorts of experiments in social interventions is how they run counter to many of our sacred notions of liberty, desert, and personal responsibility. Our public policy discourse has always been dominated by contests among competing ideologies. Often these ideologies are incommensurable in fact or in practice, grounded in competing ungrounded base premises. The promise of American pragmatism and the social science projects to which it gave birth was to set secular and sacred religions aside in the forums of public policy debates in favor of evidence. While evidence-based approaches surely have their limits, they at least promise the possibility of a shared vocabulary and, perhaps, a consensus on the best imperfect way forward in the face of social challenges that require coordinated action.